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Mailbox Books Library Service For The Homebound
Application For Service


Full Name: Telephone: Street Address:
City: County: Zip Code:
Email Address: Birth Date:
There is no charge to Gwinnett County residents. Out of county fees are $30.00/year.
Gender:
 (This information will be used for
demographic statistics only.)
    Do you already have a library card?
Female Male
 		No Yes Card#

To avoid duplication, it is necessary for the Library to keep a record of the materials sent to you.
Do you give permission for the Library to keep this record? Yes No

Statement of Eligibility - please select one:
I am homebound because of:
Age Chronic Illness Visual Impairment
Physical Disabiltiy Temporary Condition
Other(Please state reason)

I will be responsible for any lost or damaged materials. I understand that past due accounts of over $25.00 will be
referred to a collection agency and I will be charged an additional $10.00. I understand that a parent or legal guardian's
decision concerning checkout options available to minors is necessary to issue a library card to a minor before this
service begins, and that staff will be happy to discuss the options with me.
Name:Date:
Parent/Guardian(for applicants under 18):

Important: Please complete the following Material Selection Information.
MATERIAL SELECTION INFORMATION:
The library will send specific titles you request if they are available, or we will choose materials for you.
If you wish to have materials selected for you, the library needs information about your interests.
Please check the types of materials and subjects you prefer.

Please Send Me Books:
Large Print Standard Print Books Paperbacks Magazine
Authors you like: Preferred magazine titles:
Please send me audiovisual materials:
Books On CD
Videos(limited selection, non-fiction DVDs(non-fiction only)
How many items would you like in each shipment?
Topic Selections - Check as many of these categories as you wish:
Adventure Stories Animal Stories Best Sellers Biographies
Classic Novels Crafts & Art Cooking Detective & Mystery
Family Stories Fantasy Health & Medicine Historical Fiction
History - U.S. History - World Horror Humor
Inspirational Fiction Poetry Romance Science fiction
Short Stories Southern Sports Suspense
Travel True Crime War Westerns
Other:
Please tell us of some books you have read and enjoyed?
Qualified customers will be sent materials under the U.S. Postal Service’s “Free Matter for the Blind and
Handicapped” program. The library pays the postage for other customers.

You may now print and mail this application to the following address, OR simply click the SUBMIT button
below to send your application in electronically. For more information call 770-822-5366.
mail application to:
Mailbox Books
Gwinnett County Public Library
1001 Lawrenceville Highway Lawrenceville, GA 30046-4707
OR
Submit application electronically:
    
The Gwinnett County Public Library promotes accessible library services to all persons and does
not discriminate on the basis of race, religion, color, sex, age, national origin or disability.